THE LUNG REFLEX OF ABRAMS.

253 The second theory, to which I think strong objection shouid be made, is that of the nature of the great intestine, which Mr. Stanmore Bishop regards as "the slop stone and drain"to carry ofE the. refuse of the stomach and small intestine. It is not nature’s habit to use seven or eight feet of an elaborate tube furnished with a carpet of glands and lymphoid tissue, supplied most richly with arteries, veins, and lymphatics, with a delicate and easily discrganised nervous mechanism, to play the part of an excretory duct or cloaca. Yet Metchnikoffand Dr. E. Barclay-Smith4 have each concluded that the great intestine, as far as man is concerned, is a useless and dangerous structure and that its presence in man is a blunder on the part of nature which, however, can be obviated by the aid of the surgeon. The Metchnikoffian theory of the great intestine rests on two facts : (1) we do not know the function of the great intestine ; and (2) the health of the body is improved by the removal of a diseased great intestine. There is no evidence that the excision of a healthy or normal great intestine leads to an improvement of the well being of the individual. " My reason for protesting against the " syphon drain-pipe theory of the great intestine is that, were it accepted by a your ger generation, it would retard a much. needed inquiry into the functions of the colon and the normal stimuli whereby its nervous and muscular mechanisms are set in

operation,

4 ought

view of the comparative anatomist it inference to suppose that it would be easier, did we know the functions of the several segments of the alimentary canal, to adapt the human diet to the canal than by surgical interference to modify the canal to suit the artificial diet of civilisation. From the

point of logical

seems a more

T

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0.’--

—-

A.

t:ttn—

KEITH, M.D. Aberd.

THE BORDERLANDS OF INFECTIOUS DISEASES AND THEIR

MANAGEMENT. To the Editors

hospitals

to be

I am,

Sirs, yours faithfully,

-

CLEMENT DUKES.

CHLORETONE IN SEA-SICKNESS. To the Editors of THE LANCET. SIRS,-As was through the correspondence columns of your valued journal that I was first made acquainted with the efficacy of chloretone in sea-sickness, and as I havejust recently realifed the value of that information, I deem it my duty to contribute through the same medium my grateful testimony in confirmation of your correspondents’ reports. My daughter (aged about 20 years) is so fond of the sea that she always prefers boat to train, notwithstanding the fact that she has (until this last trip) invariably had to undergo the ordeal of at least 24 hours’ sea-sickness. She sailed from London Docks on Dec. 30th per s.s. Avon to Grangemouth and returned by same steamer last Friday morning. On this occasion she took with her a supply of chloretone capsules, five grains each, and for the first time in her life made the sea trip not only without sickness In fact, she but with improved appetite and spirits. partook with relish of fats and vegetables, things that she could not tolerate at home. She attributes (I believe rightly) her immunity to the chloretone capsules, two of which she took before setting out and nturning. She was directed to take one every two hours if threatened with sickness, but fortunately occasion did not arise, although the trip both ways was very rough, the vessel shipping numerous heavy seas and rolling very much. I may also add that I have found the same preparation useful in some cases of insomnia, reflex headache and vomiting, and would very much like if some of your numerous readers could favour THE LANCET with their experience of its effects in these directions and such explanation of its action as may assist in indicating suitable cases and mode of administration. Apologising for the unintended length of this communicaI am, Sirs, yours faithfully, it

tion,

--

JOHN

DUNLOP,

L.R.C.P.

Edin., &c.

of THE LANCET.

to be on the verge of obtaining the clear SiRs,-We white light of truth on the second part of this subject, thanks to the manly courage of Dr. H. E. J. Biss in revealing some of the facts. The question of the borderlands of infectious diseases is eclipsed for the moment by the facts disclosed as to the critical state of the Metropolitan Asylums Board’s hospitals and, as a matter of fact, by many medical officers of health as to isolation hospitals generally, as well as notably by Mr. E. D. Marriott of Nottingham. The facts divulged from time to time for some years past have caused some misgiving to many, but no one outside an isolation hospital could credit that they were as serious as stated by Dr. Biss in his last letter. If during five years in the Metropolitan Asylums Board’s hospitals 2562 patients who had been admitted for scarlet fever were attacked with diphtheria during their convalescence in hospital and if about the same number who were admitted into hospital suffering from diphtheria likewise sickened with scarlet fever then I think the strongest case is made out for an immediate inquiry so that the medical staffs of these hospitals may have an opportunity of unburdening their minds, for they must be fulfilling their duties with heavy hearts. The darkest days of ophthalmia in barrack schools pale before such revelations of, at least, some of these miscalled isolation hospitals. If the results made known are only obtainable after isolation hospitals are constructed secundum artem, and under efficient management, then there is only one course openthe doors must be closed. But I am still loth to believe that they cannot be rendered serviceable for their purpose, notwithstanding Dr. Biss’s alarming figures. I therefore join in calling upon those who are answerable for the construction and management of these hospitals to institute a public inquiry by a competent and disinterested commission without delay. Should those in authority burke an inquiry it will become a question of "urgent public importance " in the House of Commons. Meanwhile I would go further and say, seem

not the construction of new isolation

] pending an inquiry ? prohibited

THE LUNG REFLEX OF ABRAMS. To the Editors of THE LANCET. SiRS,—I am again obliged to correct Dr. Campbell’s statement to the effect that I acknowledge the action of the re-piratory muscles "in explaining reflex pulmonary expansion." Yes ; afttrthe expansion has passed a certain point, already frequently pointed out, and safeguarded in my last letter by the words after passive recoil of the chest has done its part." I am afraid I must admit my inability to follow Dr. Campbell in his comparison of the action of an "

entire organ, like the heart, with that of a group of muscles only forming part of a complicated system of machinery, nor shall I venture to entertain the somewhat mystical conception that muscles when relaxing may be at the same time contracting, more especially as this is based on observations which Dr. Campbell has made upon himself. Now in respect of lung contraction in a limited area Dr. Campbell dismisses physiological experiments as valueless, believing, curiously enough, that in such the lungs are necessarily subjected to a positive pressure. By no means. I intended to refer more particularly to portions of lung inclosed in the plethysmograph from which the air had been exhausttd. If, as Dr. Campbell fancies, the effect of bronchiolar constriction is to drive the contained air backwards into the alveoli, how is it that the manometer records an increase of pressure? The vagus acts chiefly on the sm&llest bronchioles and what may be termed the air wave in lung contraction travels from within outwards. If, on the other hand, the air were driven inwards, not only would there be no rise of pressure but the total lung volume would remain constant for the time being. As the reverse of both these conditions occurs the hypothesis of an alveolar inflation is insusceptible of serious consideration. Even clinical observation proves that sudden obstruction of a bronchus cases collapse of the pertaining lurg territory. Finally, the question is put, 3 The Nature of Man. English translation, by P. C. Mitchell. Could a vagus stimulation produce a pulmonary contraction London, 1903. to cause a darkening (i.e., diminished brightness) 4 Proceedings of the Cambridge Philosophical Society, vol. xii., sufficient in the fluoroscopic field and a dulling of the percussion note? Part I., 1903.

254 I answer, certainly. In the latter case it is only necessary to recall the fact that in the normal lung the percussion note at the end of expiration is less resonant than that yielded at the end of inspiration.

expressed with diffidence, but the medical profession has now had experience for nearly 50 years of a body constituted in an analogous manner, and the experience cannot be described as encouraging. The General Medical Council is 0:-partly composed of members appointed by corporations the A. G. AULD. proceedings of which it was collectively intended to control, and partly of members nominated by the Crown or elected ’" * In closing this correspondence last week we otiered the profession. The corporation members have certainly Dr. Auld an opportunity of reply of which by an oversight by been expected, in addition to their duties on the Council, to This correspondence must now take care of the interests of the bodies appointing them; he did not avail himself. and in this respect they have occupied positions fairly cease.-ED. L. analogous to those which the representatives of hospitals would occupy on the suggested board. The Crown and the PROFESSIONAL ETHICS. elected members have been looked upon somewhat in the To tAe Editors of THE LANCET. light of watchdogs over their colleagues, and have occupied analogous to those which the members SIRS,-I inclose the facts of a recent incident that positions fairlythe collecting funds would occupy on the occurred in my practice in the hope that you will publish appointed by board. The efforts of hospital representatives suggested I it can vouch them, with comments, if you think desirable. for the truth of every word of the statement and can only would be primarily directed towards the attainment of the add that in myjudgment many offences "infamous in a pro- maximum of independence for their several institutions, fessional sense " are paltry compared with this exhibition of and towards combination when this independence appeared to them to be in danger ; while the efforts of the greed and lack of professional honour. representatives of the funds would be mainly directed toI am, Sirs, yours faithfully, wards the attainment of the largest possible measure of conF.R.C.S. Jan.l0th.l904. T..............

1

PS.-I inclose my card. [INCLOSURE.] A patient, living about 20 miles from London, was recently found by his medical adviser to be suffering from prostatic caleulus, a uric acid stone having become impacted in the prostatic urethra. Efforts were ilrst made, as the stone was not supposed to be large, to dissolve it sufficiently to pass per urethram. These eff rts failing it was decided to consult a London specialist, and accordingly the practitioner wrote a careful history of the case to the selected man and arranged an appointment. The specialist confirmed the diagnosis, alleging great danger in delay, telling him that his doctor had acted wrongly in his treatment and urging him immediately to submit himself to operation. It was ultimately settled that he should go into a public hospital, to which the specialist was attached, on tha following day in order that it might be done. In consideration of this the patient-with a considerable family, and living in a house of about ,B35 per annum rental value-was induced to promise to send that same night to the specialist a fee of 20 guineas over and above the two-guinea c)nsulting fee. But he was carefully enjoined not to tell his doctor or anyone else of this transaction. He returned home that afternoon, calling

upon his medical adviser on the way with a message from the " consultant" that he was too busy to write anything about the case, and stating that there was a " great big stone " which ought never to have been left so long. Early the following morning he sent an urgent message to his doctor to the effect that he could not pass his water and on the doctor’s arrival the stone had been happily passed ; it was of the shape of a small sparrow’s egg and measured five-eighths of an inch in length and one inch in girth at its middle-that is to say, its largest transverse diameter was about one-twenty-fourth of an inch more than that of a No. 12 catheter - it weighed 14 grains nearly when dry and showed ample appearance of superficial disintegration as a result of the efforts to dissolve it. The necessity for the operation having passed the patient began to feel anxious about his 20 guineas which he had duly sent off the previous night and only on that account did he divulge the fact of the payment. It is well to be able to record that he got it back, but the medical practitioner did not receive a single word of advice or any report of the case from the consultant whom he had approached for help and guidance. The patient, however, received a letter returning his cheque and containing instructions to the effect that should any bleeding or dysuria occur he had better go up to the specialist at once :

LONDON HOSPITALS AND CENTRAL CONTROL. To tAe Editors of THE LANOET. the letter which you have already done me the favour to publish upon this subject I did not get beyond the position that some central control of hospitals would almost certainly be advantageous ; and I will now, with your permission, approach the manner in which such control might be obtained. The’letter of Dr. Lauriston E. Shaw in your issue of Jan. 16th, p. 186, and letters which have appeared in the Tinaes from the original writer upon the question, from the Hon. Sydney Holland, and from Mr. Loch, are all of them valuable contributions to the formation of a sound judgment upon a very important but very difficult and complicated problem, and proceed from writers whose opinions are entitled to consideration and respect. Among these writers there seems to be a general agreement that a useful board of control might be formed by some process of election or nomination from the committees of the great collecting funds and from the governing authorities of the hospitals themselves. Dissent from such a view, resting upon such authority, can only be

SIRS,—In

trol. The inevitable result would be a deadlock. The General Medical Council, in the 48 years of its existence, has not yet been able to secure the proper preliminary education of medical students ; and has lately been so evenly divided upon a crucial question that an appeal to the casting vote of the President was only avoided by the departure of one of the members from the meeting room. The members of the Council are not to blame. There are too many of them, their powers are inadequate to the proper performance of their supposed duties, and some of them are compelled to consider the apparent interests of the corporations which they are collectively intended to control. The proposed hospital board would, in my humble judgment, break down in a precisely similar manner, even apart from the consideration that the election of members by the funds would afford no security that the gentlemen (or ladies) elected had any real knowledge of hospital management or any competence to decide the questions which would be submitted to them. The board would, in my opinion, possess too much of an amateur character, it would of necessity be far too numerous, it would have no continuity of policy, and it would break in pieces under the stress of internal dissension. It has been suggested, I think by Mr. Sydney Holland, that the Government might with propriety subsidise the hospitals by an augmentation of their revenue from public funds equal in amount to the total of the voluntary contributions ; and it has often been suggested tha-,hospitals fulfilling certain conditions of usefulness and efficiencymight with propriety be exempted from the payment of local rates. It seems to me that the adoption of one or both of these suggestions is eminently desirable in the interests of the public and that only by adopting one or both of them could control in the public interest be secured without the sacrifice of independence. It is a national scandal that the hospitals receive no subvention, and that the persons able to contribute to their support, but who wholly fail to do so, nevertheless share equally with contributors in the benefits which they confer upon the entire community. Antiseptic surgery is as much at the command of a miser who never gave a shilling to a hospital in his life as it is at that of Mr. Herring himself. I should rejoice to see the miser reached by the tax collector or by the rate-collector, but any notion of direct or complete hospital control by the Government or by a municipality is unthinkable. No one could endure to see St. Bartholomew’s reduced to the condition of the War Office, or to see the municipality of Marylebone turn away its attention from electric lighting to the management of the Middlesex Hospital. The distribution of a Government subvention or the grant of immunity from local rates would require, of course, to be supervised by some competent authority, and would permit the Government of the country to appoint one. It should, I think, be a commission of three persons, comparable to the Charity Commission, and should be a paid body with no other official duties or responsibilities. Its business should be to make itself thoroughly conversant with the management of all hospitals which through their secretaries or committees expressed a desire to participate in the subvention or the immunity which it was the function of the commission to administer, and to lay down the conditions